Title: Blunt trauma abdomen with isolated infarcted left lateral
segment of the Liver
A 13-years-old female presented to the emergency surgical department
with pain epigastrium, and shortness of breath for 3 days. She sustained
blunt abdominal trauma following motor vehicle accident three days back.
Following the injury, she was initially managed at the periphery
hospital; on deterioration was referred to our academic tertiary care
center. On general physical examination, she was conscious, oriented,
febrile, tachypneic (28 breaths/min), tachycardic (130 beats/min) with
normal blood pressure. There was no pallor. Abdominal examination
revealed tender epigastrium with guarding. Her blood investigation
showed normal hemoglobin, leukocytosis (22,000/mm3),
normal renal function tests and amylase/lipase levels, normal bilirubin
but raised liver enzymes (>3 times). On contrast computed
tomography (CT), there was a well-demarcated, absence of perfusion on
the left lateral segment to the liver suggesting infarction (Fig. 1).
The hepatic arteries, portal vein and its branches and other abdominal
organs were normal. There was no intrabdominal collection. Diagnosis of
traumatic left lateral liver segment infarct with sepsis, probably from
the bile leak from the divided liver segment was assumed, and planned
for surgery.
At surgery, there was a near complete (70%) detachment of the left
lateral segment of the liver from the falciform ligament. The injured
segment was dusky brown, pale and stained with bile leak (Fig. 2 and 3).
It was resected (left lateral segmentectomy), hemostasis secured and
area drained. Postoperatively, she improved dramatically. Her symptoms,
tachycardia, tachypnea and raised leukocytes counts improved and were
discharged on day 12. The pathological examination confirmed necrosis of
the excised segments. At 2- years follow-up, she is doing well.
The liver is the most commonly injured organ following motor vehicle
accident due to the sudden deceleration. The most frequent occurrence is
a tear between liver segments III and IV caused by the acute impact of
the liver on the hepatic ligament.1 This tear often
leads to intraperitoneal hemorrhage; but in contrast, rarely can lead to
the devascularization of the segment as observed in the present case.
This is because of the interruption of flow from the left hepatic
artery.2 A liver injury, despite the grade, if
hemodynamically stable is preferably managed non-operatively. However,
if the segment (II and III) is devascularized, with concomitant bile
leak and persistent systemic inflammatory response syndrome (SIRS), it
is best managed with resection of the segment with excellent outcome as
seen in our case.3 This scenario with typical CT and
intraoperative image is rare to see with anecdotal case reported in the
literature.1